RU2722350C2 - Method for a one-stage mammary gland reconstruction after subcutaneous radical mastectomy using a polyurethane implant placed prepectorally - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, namely to oncology. Thickness of excised skin and subcutaneous fat should be more than 1.5 cm, preoperative marking is applied to skin according to figure 1: first, median line is applied from middle of clavicle through nipple and middle of lower slope, marking the submammary fold, marking the mammary gland as a reference point for performing the subcutaneous mastectomy, then in the parasternal area in the craniocaudal direction the medial meridian is applied, and the lateral meridian is drawn along the anterior axillary line, location of skin incision is made along lower edge of areola, delineating semicircle from point A to point B, dividing areola in half, and further from point B to point B is drawn horizontal line with size of 5–6 cm towards anterior axillary line, then according to the specified marking, an skin incision is made and gland tissue is subcutaneously removed, covering tissues are separated, glandular tissue is separated from greater pectoral muscle and removed, wherein the integrity of the greater pectoral muscle without disturbing, further into the prepared skin-muscular bed on the greater pectoral muscle, without mobilizing the latter, silicone implant with polyurethane coating of appropriate size and shape is installed without using additional methods of implant covering, the latter is located only under skin and subcutaneous fat, then separate sutures are used to close subcutaneous fat and skin with an intradermal suture.EFFECT: method enables avoiding the pectoral muscle injury, reducing the operation time and volume, reducing blood loss, preserving the pectoral muscle functionality, ensure good fixation on the tissues of the anterior chest wall, which prevents the implant rotation, reduce the risk of capsular contracture and reduce the hospital bed-days; proposed operation is less traumatic and simpler technically.1 cl, 1 ex, 12 dwg

Description

The invention relates to medicine, more specifically to oncology, and can be used as a simultaneous reconstruction of the mammary gland after skin-guarding / subcutaneous radical mastectomy.

Reconstructive plastic surgery is actively used in patients with breast cancer all over the world, including in Russia, the development of new techniques is ongoing. The best aesthetic, functional results can be obtained with simultaneous reconstruction of the mammary gland. A large number of domestic and foreign works have been devoted to the reconstruction of the mammary gland using silicone endoprosthesis, which indicate a satisfactory and good cosmetic effect of such operations.

Known methods for simultaneous reconstruction of the mammary glands after subcutaneous / skin-guarding mastectomy with covering the endoprosthesis with the acellular dermal matrix, mesh implant. Studies are published in a number of foreign articles.

In 2017, a retrospective study of Steven Sigalov et al was published, where 350 patients with breast cancer underwent preectoral reconstructions with endoprostheses with additional coverage with the acellular dermal matrix.

However, minimal postoperative complications are comparable to implant placement (Prepectoral Implant-Based Breast Reconstruction: Rationale, Indications, and Preliminary Results (Steven Sigalove, G. Patrick Maxwel et al) Plastic and Reconstructive Surgery ⋅ February 2017).

According to a study by Sadaf Jafferbhoy, Mihir Chandarana et al. In 2017, from 2015 to 2016, 78 breast cancer patients underwent pre -ectoral reconstructions with additional Braxon implants (Early multicentre experience of pre-pectoral implant based immediate breast reconstruction using Braxon (Sadaf Jafferbhoy, Mihir Chandarana et al) 2017).

However, the results of the study also showed that the frequency of complications was not higher than with a subpectoral implant placement with additional coating with the acellular dermal matrix.

The closest is a method for reconstructing the mammary glands after a subcutaneous mastectomy, including placing the silicone endoprosthesis and the mesh implant in the created “pocket” and fixing it, moreover, in the standing position, marking lines of the excised skin are applied, according to figure 1: first, a straight line is drawn separating the lower and upper the quadrants of the mammary gland, the contour along the areola radius in the upper quadrants, from the point of connection of the straight line and the areola contour (a) in the inner quadrants, lay 6-7 cm towards the sternum and put point (b), from it at an angle of 30 ° towards the upper -the inner quadrant put the next point (c) and connect it to the original point (A), then from the deferred point at an angle of 30 ° to the center of the upper slope draw a straight horizontal line - 2 cm and put the next point (d), from the middle of the areola radius put a point (d) and lay up 4-5 cm, put a point (e) and arcuate parallel to the areola contour line connect it with a point (d), then all the points and the lines are transferred in a mirror image to the opposite side of the mammary gland in the upper outer quadrant, then according to the intended marking, a skin incision is made, the skin with subcutaneous tissue is separated by an electric knife throughout the entire dome of the mammary gland, highlighting the parenchyma of the gland and removing it into the resulting “skin cover” an endoprosthesis is placed, wrapped in the form of a “cap” with a mesh implant, the mesh is tightened at the upper pole of the endoprosthesis until the mesh is in close contact with the implant, the mesh implant is sutured with nodal sutures at three points - the middle of the medial contour of the endoprosthesis, the lateral and upper one - to the pectoralis major muscle, the operation is completed drainage of the "pocket" of the endoprosthesis and layered wound closure (RU 2653803 C2).

However, the known method has several disadvantages:

- the use of an additional endoprosthesis cover using a mesh implant increases the risk of complications due to the use of additional synthetic material, namely, prolonged seromas;

- lengthening of operating time;

- additional costs for consumables.

In the available open Russian and foreign sources of published information, a similar method could not be found.

The technical result of the present invention is to obtain the natural appearance of the mammary gland, reducing the risk of capsular contracture after reconstruction, reducing trauma and maintaining the functionality of the pectoralis major muscle.

There are no scientific published data on the preectoral placement of endoprostheses without additional coverage in the literature.

The technical result is achieved by the fact that, as in the known method in a standing position, marking lines of the excised skin are applied, according to the intended marking, a skin incision is made, a subcutaneous radical mastectomy is performed and a silicone implant with a polyurethane coating is installed.

A feature of the proposed method is that the thickness of the skin and subcutaneous fat should be more than 1.5 cm, preoperative marking is applied to the skin, according to figure 1: first, the midline is applied, from the middle of the clavicle through the nipple and the middle of the lower slope, submammary fold, note the breast field as a guideline for performing subcutaneous mastectomy, then in the parasternal region in the craniocaudal direction the medial meridian is applied and the lateral meridian is drawn along the anterior axillary line, the skin incision is located along the lower edge of the areola, outlining a semicircle from point A to point B, dividing the areola in half, and then from point B to point C, draw a horizontal line measuring 5-6 cm in the direction of the anterior axillary line, then according to the intended marking, a skin incision is made and the gland tissue is subcutaneously removed, the integumentary tissues are separated, the glandular tissue is separated from the pectoralis major muscle and delete, maintaining the integrity of the latter, then in the prepared musculoskeletal bed on the pectoralis major muscle, without mobilizing the latter, a silicone implant with a polyurethane coating of the appropriate size and shape is installed, without using additional methods of covering the implant, the latter is located only under the skin and subcutaneous fat, after which the sutures are sutured subcutaneous tissue and skin by intradermal suture.

The proposed method is illustrated by a detailed description and illustrations, which depict:

FIG. 1 - a) marking the middle line; b) marking the middle meridian of the mammary gland: 1. Mediaclavicularis from the middle of the clavicle through the nipple, the middle of the lower slope, submammary fold; c) marking of the submammary fold; d) in the parasternal region in the craniocaudal direction, a medial meridian is applied; e) a lateral meridian is drawn along the anterior axillary line; f) along the lower edge of the areola, outlining a semicircle from point A to point B (halving the areola), and further from point B to point C, draw a horizontal line measuring 5-6 cm in the direction of the anterior axillary line.

FIG. 2 - Skin incision.

FIG. 3 a, b - Separation of breast tissue from the skin.

FIG. 4 a, b - Separation of breast tissue from the muscle.

FIG. 5 - Remote breast tissue.

FIG. 6 - Establishment of drainage.

FIG. 7 - Selection of the desired implant volume using a sizer.

FIG. 8 - Installation of a polyurethane implant.

FIG. 9 - Suturing of the postoperative wound.

FIG. 10 - Intradermal suture.

FIG. 11 - View of the patient before surgery: a, b, c - in the direct and lateral projections.

FIG. 12 - View of the patient 2 months after the operation: a, b, c - in the direct and lateral projections.

The method is as follows.

An important criterion for selecting patients for pre -ectoral reconstruction of the mammary gland is the thickness of the skin and subcutaneous fat, which should be more than 1.5 cm. At the first stage, the implant is selected and preoperative marking is performed in a standing position, according to figure 1 a-e: middle marking lines (Fig. 1 a); layout of the middle meridian of the mammary gland - 1. Mediaclavicularis from the middle of the clavicle through the nipple, the middle of the lower slope, submammary fold (Fig. 1 b); marking the submammary fold (Fig. 1 c), raising the arms up, mark the breast field - a guideline for performing subcutaneous mastectomy, in the parasternal region, the medial meridian is applied in the craniocaudal direction and the lateral meridian is drawn along the anterior axillary line (Fig. 1 d). The last step marks the location of the skin incision along the lower edge of the areola, outlining a semicircle from point A to point B, dividing the areola in half, and then from point B to point C, draw a horizontal line 5-6 cm in size towards the front axillary line (Fig. 1 e).

The implant is selected individually for each patient, depending on three parameters: the width, height of the spot of the breast, as well as the projection of the gland itself.

In the operating room, in the position of the patient lying on his back under anesthesia, a subcutaneous radical mastectomy is performed according to preliminary marking (Fig. 1 a-e). A skin incision is performed (Fig. 2), gland tissue is removed subcutaneously, Scarpa fascia is the border of separation from the skin (Fig. 3 a, b), the integumentary tissues are separated according to the marking of the borders of the base (spot) of the mammary gland. Next, the glandular tissue is separated from the pectoralis major muscle (Fig. 4 a, b) and removed, while maintaining the integrity of the pectoralis major muscle (Fig. 5). The formed bed is washed with an antiseptic solution and an antibiotic solution (amikacin). Next, a drainage is installed through the contra-hole (Fig. 6). The implant is selected using a sizer (Fig. 7). After the selected size, using the Farabef hooks, the wound is expanded, through which a silicone endoprosthesis with a polyurethane coating is installed, pre-treated with an antibiotic solution (Fig. 8). After the implant is installed, the installed implant is monitored in the bed and the integumentary tissues are distributed on the surface of the endoprosthesis, preventing folding. The wound is sutured with two or three-row sutures (Fig. 9) and an intradermal continuous suture is applied (Fig. 10). Next, the sentinel lymph node is determined, or the regional lymphatic collector is removed as a single block in the case of a metastatically affected lymph node.

Due to the polyurethane coating, the endoprosthesis is firmly held in the formed bed, the polyurethane fibers are firmly fused with the subcutaneous tissue due to the adhesive properties of the polyurethane shell. Taking into account the strong fixation of the endoprosthesis to the surrounding tissues, it is more advisable to install the implant in the lower part of the formed pocket as much as possible.

A clinical example of the method.

Patient Shch., 69 years old, Turned to the Moscow Research Institute of Medicine. P.A. Herzen Department of Oncology and Reconstructive Plastic Surgery of the breast and skin in April 2018 with complaints of the presence of a tumor-like formation in the right mammary gland. During the examination, the diagnosis was established: cancer of the right breast of the first stage cT1 (m) N0M0G2, luminal type A, clinical group 2 (Fig. 11). Surgical intervention was performed: after preliminary marking (Fig. 1 a-e), in the supine position under endotracheal anesthesia, a radical subcutaneous mastectomy was performed on the right and the sentinel lymph node was determined from separate access with the drug removed in a single block, hemostasis was performed. In the formed skin-muscle bed on the surface of the pectoralis major muscle, a silicone implant with a polyurethane coating 435 XN (Fig. 8) and active drainage are installed. Then carried out suturing of fiber and skin (Fig. 9, Fig. 10).

On the 5th day, the drainage tubes were removed. The patient was discharged from the hospital in satisfactory condition with a good aesthetic effect. After 2 months, neither Cicatricial deformities of the mammary gland nor subcutaneous seals were noted, a good aesthetic result of the reconstructed mammary gland was observed (Fig. 12).

The proposed method preserves the pectoralis major and minor.

Thus, the feasibility study consists in:

- the advantage of pre -ectoral reconstruction with a silicone implant in the absence of damage to the pectoralis major muscle;

- less traumatic nature of the operation;

- a simpler operation technique;

- reducing the time and volume of the operation;

- reduction in blood loss;

- maintaining the functionality of the pectoralis major muscle;

- good fixation on the tissues of the anterior chest wall, which prevents the rotation of the implant;

- reducing the risk of capsular contracture;

- reduction of hospital days.

Claims (1)

The method of simultaneous reconstruction of the mammary gland after a subcutaneous radical mastectomy using a polyurethane implant installed preectrally, including marking of the excised skin in a standing position, a skin incision is made according to the intended marking, a subcutaneous radical mastectomy is performed and a silicone implant with a polyurethane coating is installed, characterized in that the skin thickness and subcutaneous fat should be more than 1.5 cm, preoperative marking is applied to the skin according to figure 1: first, the midline is applied, from the middle of the clavicle through the nipple and the middle of the lower slope, marking the submammary fold, mark the breast field as a guideline for performing subcutaneous mastectomy, then in the parasternal region in the craniocaudal direction, the medial meridian is applied and the lateral meridian is drawn along the anterior axillary line, the skin incision is noted along the lower edge of the areola, outlining a semicircle from point A to point B, I cut the areola in half, and then from point B to point C draw a horizontal line of 5-6 cm in size towards the front axillary line, then according to the intended marking, a skin incision is made and the gland tissue is subcutaneously removed, the integumentary tissues are separated, the glandular tissue is separated from the pectoralis major muscle and removed, while maintaining the integrity of the pectoralis major muscle without breaking, then in the prepared cutaneous muscle bed on the pectoralis major muscle, without mobilizing the latter, install a silicone implant with a polyurethane coating of the appropriate size and shape, without using additional methods of covering the implant, the latter is located only under skin and subcutaneous fat, after which separate sutures are used to suture the subcutaneous tissue and skin with an intradermal suture.

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